Provider Demographics
NPI:1043423718
Name:SHAW, ROSE MARY (PSYD)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MARY
Last Name:SHAW
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 XENIA AVE
Mailing Address - Street 2:
Mailing Address - City:YELLOW SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45387-1123
Mailing Address - Country:US
Mailing Address - Phone:937-769-5019
Mailing Address - Fax:937-769-5019
Practice Address - Street 1:1525 XENIA AVE
Practice Address - Street 2:
Practice Address - City:YELLOW SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45387-1123
Practice Address - Country:US
Practice Address - Phone:937-769-5019
Practice Address - Fax:937-769-5019
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6323103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical